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Percutaneous nephrolithotomy: a cause of specific and iatrogenic thoracic complications

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Original Article / Özgün Makale

doi: 10.5606/tgkdc.dergisi.2013.7928

Türk Göğüs Kalp Damar Cerrahisi Dergisi 2013;21(4):987-989

Percutaneous nephrolithotomy: a cause of specific and iatrogenic

thoracic complications

Perkütan nefrolitotomi: Spesifik ve iyatrojenik toraks komplikasyonlarının bir nedeni

Rasih Yazkan,1 Taylan Oksay,2 Alper Özorak,2 İsa Döngel,1 Sefa Alperen Öztürk,2 Alim Koşar2

1Department of Thoracic Surgery, Medical Faculty of Süleyman Demirel University, Isparta, Turkey 2Department of Urology, Medical Faculty of Süleyman Demirel University, Isparta, Turkey

Amaç: Bu çalışmada, genellikle perkütan nefrolitoto-mide karşılaşılan torasik komplikasyonlar değerlendi-rildi.

Ça­lış­ma­ pla­nı:­ Şubat 2005 - Eylül 2012 tarihleri ara-sında 932 hastaya (586 erkek, 346 kadın; ort. yaş 44.98±16.35 yıl; dağılım 2-85 yıl) böbrek taşı nedeni ile perkütan nefrolitotomi uygulandı. Bütün hastalar ameli-yat öncesi arka-ön akciğer grafisi ile değerlendirilir iken, suprakostal girişim yapılan ve toraks komplikasyonundan şüphelenilen hastaların tümü ameliyat sonrası arka-ön akciğer grafisi ile değerlendirildi. Toraks komplikasyonlu hastaların tümüne tüp torakostomi uygulandı.

Bul gu lar: Sekiz yüz kırk dokuz hastada (%91) sub-costal girişim, 83 hastada (%9) suprakostal girişim yapıldı. On sekiz hastada (%1.93) toraks komplikas-yonu gelişti. Bunlar 13 hastada (%1.39) suprakostal ve beş hastada (%0.54) subkostal yaklaşım idi. On bir suprakostal girişim 12. kaburga üzerinden ve iki suprakostal girişim 11. kaburga üzerinden yapıldı. Tüm komplikasyonlar değerlendirildiğinde 12 hemo-toraks, dört pnömotoraks ve iki ürinotoraks tespit edildi.

So­nuç:­ Perkütan nefrolitotomi iyatrojenik toraks komp-likasyonlarının bir nedenidir ve suprakostal yaklaşım, subkostal yaklaşıma kıyasla, daha fazla torasik kompli-kasyon oranına sahiptir. Özellikle her suprakostal giri-şimden sonra erken ameliyat sonrası oturur ya da ayakta durur pozisyonda arka-ön akciğer grafisi, torasik komp-likasyonların erken tanısı için temel tanı aracıdır. Bu tip komplikasyonların tedavisi için tüp torakostomi sıklıkla yeterlidir.

Anah tar söz cük ler: Komplikasyon; iyatrojenik; perkütan nefro-litotomi; torasik.

Background:­ This study aims to evaluate thoracic complications which are usually encountered in percutaneous nephrolithotomy.

Methods: Between February 2005 and September 2012, 932 patients (586 males, 346 females; mean age 44.98±16.35 years; range 2 to 85 years) underwent percutaneous nephrolithotomy due to the nephrolithiasis. All patients were evaluated with preoperative posteroanterior chest X-ray while all patients who had supracostal access and who had suspected thoracic complications were evaluated with postoperative posteroanterior chest X-rays. Tube thoracostomy was performed in all patients with thoracic complications. Results:­A subcostal access was performed in 849 patients (91%), whereas a supracostal access was performed in 83 patients (9%). Thoracic complications were developed in 18 patients (1.93%). Of them, 13 (1.39%) were in patients with supracostal and five (0.54%) were in patients with subcostal approach. Eleven supracostal accesses were performed above the 12th rib and two supracostal accesses were above the 11th rib. When all complications were evaluated, 12 hemothoraces, four pneumothoraces, and two urinothoraces were detected.

Conclusion:­Percutaneous nephrolithotomy is a cause of iatrogenic thoracic complications and supracostal approach has a more thoracic complication rate, compared to the subcostal approach. An early postoperative posteroanterior chest X-ray in sitting or standing position following supracostal access in particular is an essential diagnostic tool for early detection of thoracic complications. The tube thoracostomy is usually sufficient for the treatment of such complications.

Key words: Complication; iatrogenic; percutaneous nephrolithotomy; thoracic.

Received: November 14, 2012 Accepted: December 29, 2012

Correspondence: Rasih Yazkan, M.D. Süleyman Demirel Üniversitesi Tıp Fakültesi Göğüs Cerrahisi Anabilim Dalı, 32260 Çünür, Isparta, Turkey.

Tel: +90 505 - 483 59 61 e-mail: drrasihyazkan@yahoo.com Available online at

www.tgkdc.dergisi.org

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Turk Gogus Kalp Dama

988

Percutaneous nephrolithotomies (PNLs) have been the preferred surgical method for treating staghorn stones, large renal stones, and some upper ureteric stones for 35 years.[1,2] Their successful removal

requires the proper placement of a percutaneous tract that provides direct access for stone manipulation.[3]

Subcostal or supracostal access is preferred depending on the stone localization. Traditionally, subcostal access is preferred for PNLs to avoid injury to the lungs and pleura.[4] However, in patients, with upper

caliceal stones, impacted upper ureteral stones, and staghorn calculi, the supracostal approach is the preferred point of access to the renal collecting system.[4]

The PNL procedure is generally safe and effective, but it is associated with a few specific complications which are mostly related to the thorax.[1,2] In addition,

when supracostal access is used, puncture is possible because of the potential risk of pneumothorax, hydrothorax, and lung injury.[3] The objective of this

study was to evaluate the thoracic complications usually encountered when performing PNLs.

PATIENTS AND METHODS

A retrospective analysis was performed on the surgical, radiological, and postoperative findings in a total of 932 patients (586 males, 346 females; mean age 44.98±16.35 years; range 2 to 85 years) who underwent PNLs due to nephrolithiasis between 2005 and 2012. The surgical intervention site was determined according to the localization of the stone. All of the patients were evaluated with a preoperative posteroanterior chest X-ray, and those who required supracostal access along with those suspected of having thoracic complications were also evaluated with an immediate postoperative posteroanterior chest X-ray to determine if a pneumothorax and/or a hydrothorax had occurred. When a hydrothorax was detected, a diagnostic thoracentesis was performed in order to make the distinction between a hemothorax or a urinothorax. In addition, a tube thoracostomy was performed on all of patients with thoracic complications. The chest tube was removed when lung reexpansion had occurred and the air and fluid leaks had stopped.

RESULTS

Subcostal access was performed on 849 (91%) patients in this study while supracostal access was performed on 83 (9%). After these procedures, thoracic complications developed in 18 of the patients (1.93%). Supracostal access was used for 13 (1.39%) of these patients, and subcostal access was utilized in the other five (0.54%).

Eleven of the supracostal access procedures were above the 12th rib, while the supracostal access was performed

above the 11th rib in two patients. When all the

complications were evaluated, 12 hemothoraces, four pneumothoraces, and two urinothoraces were detected. All of these were treated via a tube thoracostomy, and reexpansion was achieved. The length of hospital stay for the 18 patients with thoracic complications ranged from 6-20 days.

DISCUSSION

Transthoracic fine-needle aspiration biopsies, pleural biopsies, and transbronchial lung biopsies are the most common causes of iatrogenic thoracic complications along with subclavian vein catheterizations, thoracentesis, and positive-pressure ventilation.[5]

However, in this article we focused solely on the different causes of iatrogenic thoracic complications due to PNLs.

Percutaneous renal surgery via the supracostal approach has the advantage of being able to manage a number of renal and ureteral conditions by providing direct access to the upper pole calculi, ureteropelvic junction, and proximal ureter.[4] During this type

of surgery, subcostal access is preferred because it carries a very low risk of injury to the lungs and pleura. On the other hand, in some situations, a supracostal approach may provide more direct access and achieve more satisfactory results than the subcostal approach.[4]

Complications after PNLs are not rare and have been reported to occur in up to 83% of the cases.[6]

These are mostly clinically negligible, with minor bleeding or fever often occurring.[7] The frequency

of major complications has been reported as 0.9-4.7% for septicemia, 0.6-1.4% for renal hemorrhage requiring intervention, 2.3-3.1% for pleural injury, and 0.2-0.8% for colonic injury.[7] Michel et al.[8] noted

that the most common complication encountered after undergoing a PNL was fever (21-32%) followed by transfusion (0-17.5%), extravasation (7.2%), and sepsis (0.3-4.7%).[6] The overall complication rate

of 33.2% reported in their review is consistent with the rates that have been reported by others. For example, Tefekli et al.[9] found complications

in 29.2% of 811 subjects who underwent PNLs.[6]

However, in this study, we only evaluated the thoracic complications which required a consultation with a thoracic surgeon, which probably was the reason for our lower complication rate.

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Yazkan et al. Percutaneous nephrolithotomy

989 tracts in two other studies,[2,10] whereas in our study,

a total of only 18 patients (1.93%) developed thoracic complications. Additionally, our results showed that the supracostal approach has a significantly higher complication rate than the subcostal approach. It has been suggested that supra-11th rib punctures be

avoided to minimize thoracic complications in the diaphragm where they most frequently occur.[2,10]

There was a 35% complication rate with supra-11th

rib punctures versus only a 10% rate with supra-12th rib punctures. Thoracic complications included

pneumothorax, hydrothorax, hemothorax, and urinothorax in 8%.[2] The main purpose is prevention

and management of thoracic complications. If access above the 11th rib is mandatory in some

difficult cases, puncture should be performed in full expiration and also a computed tomography or ultrasonographic guided renal access will be useful to ensure a correct and uneventful percutaneous puncture.[2,11] Additionally, thoracic complications

can also be limited by avoiding supracostal access, the use of a flexible nephroscope, and ultrasound-guided puncture whenever possible.[2]

Conclusion

Undergoing a PNL can result in iatrogenic thoracic complications, with the supracostal approach demonstrating a higher complication rate than the subcostal approach. Hemothoraces, pneumothoraces, and urinothoraces may develop during the procedure which can increase the length of hospital stay and morbidity. Percutaneous nephrolithotomies are mainly used for the early diagnosis of thoracic complications plus they allow for theme to be managed more efficiently. If a supracostal approach is needed, an immediate postoperative sitting or standing posteroanterior chest X-ray is an essential diagnostic tool for the early detection of thoracic complications. A tube thoracostomy is usually sufficient for treatment of such kind of complications.

Declaration of conflicting interests

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.

REFERENCES

1. Sukumar S, Nair B, Ginil KP, Sanjeevan KV, Sanjay BH. Supracostal access for percutaneous nephrolithotomy: less morbid, more effective. Int Urol Nephrol 2008;40:263-7. 2. Seitz C, Desai M, Häcker A, Hakenberg OW, Liatsikos E,

Nagele U, et al. Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy. Eur Urol 2012;61:146-58.

3. Gupta R, Kumar A, Kapoor R, Srivastava A, Mandhani A. Prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy. BJU Int 2002;90:809-13.

4. Shaban A, Kodera A, El Ghoneimy MN, Orban TZ, Mursi K, Hegazy A. Safety and efficacy of supracostal access in percutaneous renal surgery. J Endourol 2008;22:29-34. 5. Çobanoğlu U, Hemidli S, Özusan HK. Iatrogenic pneumothorax:

analysis of 62 cases. Erciyes Medical Journal 2009;31:144-52. 6. Semins MJ, Bartik L, Chew BH, Hyams ES, Humphreys

M, Miller NL, et al. Multicenter analysis of postoperative CT findings after percutaneous nephrolithotomy: defining complication rates. Urology 2011;78:291-4.

7. Skolarikos A, de la Rosette J. Prevention and treatment of complications following percutaneous nephrolithotomy. Curr Opin Urol 2008;18:229-34.

8. Michel MS, Trojan L, Rassweiler JJ. Complications in percutaneous nephrolithotomy. Eur Urol 2007;51:899-906. 9. Tefekli A, Ali Karadag M, Tepeler K, Sari E, Berberoglu Y,

Baykal M, et al. Classification of percutaneous nephrolithotomy complications using the modified clavien grading system: looking for a standard. Eur Urol 2008;53:184-90.

10. Munver R, Delvecchio FC, Newman GE, Preminger GM. Critical analysis of supracostal access for percutaneous renal surgery. J Urol 2001;166:1242-6.

Referanslar

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